- An investigation by the HSIB into a patient death has found safety issues in the independent sector
- For the first time ever the number of people paying private hospitals directly for care (self-pay) was a third of all private admissions
- Previous recommendations to increase safety in the independent sector have not been acted on
- The independent sector continues to work in ways that could jeopardise patient safety
The safety of the independent hospital sector is once again under the spotlight in a report just released by the HSIB (Healthcare Safety Investigation Branch) – Surgical Care in Independent Hospitals – triggered by the death of a NHS patient sent to an independent hospital for bowel surgery.
The 58 year old patient of previously good health, had been diagnosed with bowel cancer and was scheduled to receive key-hole surgery at an NHS hospital to remove part of his bowel. As a result of the pandemic, his surgery and all other NHS cancer surgery was transferred to an independent hospital. Here the surgery method was changed to open bowel surgery following guidance on Covid-19 risks.
The patient’s recovery post-surgery was slow and after eight days he was transferred to intensive care at a local hospital. A scan showed a leaky bowel which led to sepsis and organ failure. The patients died soon after.
Safety recommendations made
The report made six safety recommendations, three to NHS England and NHS Improvement, one to NHSX, and two to the Care Quality Commission (CQC). These organisations must respond within 90 days.
The recommendations cover communication between the NHS and independent sector, correct assessment of the capabilities and capacity of independent hospitals, the use of standardised care post-surgery, and better assessment for frailty of younger patients.
Waiting lists pushing people to the independent sector
This report comes at a time when more and more people are turning to the independent sector due to the waiting lists for surgery on the NHS.
For the first time ever the number of people paying private hospitals directly for care was a third (32.9%) of all private admissions, according to data from the Private Healthcare Information Network (PHIN). The number of self-paying patients, not those funded by insurance policies, was up 30% from April to June 2021, compared to the corresponding period in 2019.
Self-pay is at its highest among 60-79 year olds; not surprising as insurance policies typically do not cover pre-existing conditions so rarely cover older people. These are patients taking out loans, using savings, or borrowing from family and friends. From April to June 2021, 65,000 people chose self-pay in order to pay for care.
Certain procedures attract more self-pay patients than others, including cataract surgery and hip replacement, which according to PHIN data are both now more commonly self-funded than paid for through insurance.
And the number of people paying for private care is likely to rise still further; a September survey by Engage Britain shows one in five people say they have been forced to use private healthcare, because they couldn’t get the NHS treatment they needed.
The NHS also continues to use the independent sector as a means to reduce its waiting list, which now stands at 5.7 million.
Is the independent sector better/safer?
Patients who pay for surgery via self-pay, through insurance policies, or who are transferred to the independent sector by the NHS often have a perception that treatment in a private hospital will be superior. However, this belief of superiority relates almost entirely to aesthetic factors; the hospitals tend to be more comfortable and visually attractive, and you get your own room.
In 2018 a report from the Care Quality Commission (CQC) found that two in five private hospitals were failing to meet safety standards intended to protect the public from harm. This prompted Jeremy Hunt, the then Health Secretary, to give the private providers two weeks to come up with a plan to “get their house in order” on safety and quality or else face tough sanctions imposed by the government.
In 2017, the safety of private hospitals hit the headlines when the surgeon Ian Paterson was jailed for 20 years after being found guilty of wounding with intent after carrying out unnecessary surgery on thousands of women over 14 years.
So did either of these two events change things in the private hospital market? The Paterson scandal led to an inquiry that released a damning report in February 2020 stating that the private healthcare system he worked in was “dysfunctional at almost every level”. However, it’s over a year later and the government has yet to make the major changes in the report that would have improved patient safety in private hospitals.
The sector lacks transparency
A major criticism was the sector’s lack of transparency. In 2014, the Private Healthcare Information Network (PHIN) was established to bring greater transparency to the private health sector. However, it wasn’t until 2020 that the first data on Never Events was published. These events are preventable patient safety incidents of the most serious category (such as operating on the wrong body part or administration of the wrong drug).
Twenty-one ‘Never Events’ were reported for 2019, but more than 300 hospitals or PPUs were unable or unwilling to hand over the data. At the time the Centre for Health and the Public Interest, a social care and health think tank, noted the lack of data from more than 300 hospitals meant there was a continuing lack of transparency. Transparency has not improved as the latest data for 1 April 2020 to 31 March 2021 reported 16 ‘Never Events’ from 257 out of 641 independent hospitals and NHS private patient units (PPUs). Although this covers 86% of patient volume in the sector, a considerable amount of information is still missing.
In contrast, all ‘Never Events’ are reported by the NHS. No unit or hospital avoids reporting them.
The PHIN notes on its website that when looking for a private hospital patients should check whether it is reporting its ‘Never Events’ and if it isn’t, what does this say about safety in the hospital, and what could this mean for your care? And if it has reported Never Events then what type of incident was it, what did they do about it and might this be relevant to your care?
Lack of ICU and staff levels are major safety issues
A major safety issue with the independent hospital sector, as seen in the recent HSIB report, is the lack of intensive care (ICU) beds. The private sector relies entirely on the NHS for access to ICU. A lack of these beds means the hospitals should not carry out surgery on patients in high-risk groups, as assessed using NICE guideline NG45 (2016). As the case investigated by the HSIB shows well however, is that the assessment process is not always accurate and patients may still need ICU. In this case patients are transported to a nearby NHS hospital with the consequent delay in getting the patient into ICU; an ambulance has to be called, then the patient is taken to a hospital with a free ICU bed – this could take under half an hour or it could take much longer. Transfer to ICU in an NHS hospital would be a matter of minutes not hours.
There continues to be an issue in private hospitals linked to the sector’s use of Registered Medical Officers (RMO) to look after post-surgery patients. An RMO is generally at the start of their medical career and will lack experience of all of the various conditions and complications that can occur among their patients. An RMOs contract usually requires them to be on-site at a specific hospital at all times, but they are often the only doctor on-site outside office hours.
In June 2021, the GMC published a survey of RMOs working in the UK private sector. They found that RMOs face challenges in the form of high workloads, struggling to reach senior colleagues for support with patients, lack of time for training, and high levels of responsibility. The survey revealed that around half (47%) of RMOs could “recall witnessing a situation in which they believe a patient’s safety or care was being compromised when being treated by a doctor.”
RMOs working in the private sector are supposed to receive supervision and mentoring, however many were not impressed by the quality. A sizable minority (29%) felt that supervision was poor and a higher proportion of RMOs felt the quality of mentoring they received was poor (39%).
Safety can also be compromised by what many think of as a benefit of private healthcare – a private room. You will be checked periodically but you are not easily observable, whereas NHS patients are usually placed in wards or small bays where the beds are separated by curtains, where you can be easily observed. Patients at-risk of deteriorating are likely to be closer to the nurse’s station.
Who monitors the sector?
As in the NHS, the independent sector is monitored by the CQC. It was this organisation’s report back in 2018, and the Ian Paterson scandal, that prompted a closer look at the sector. Hospital ratings are available on the CQC website and many of the independent hospitals continue to be rated ‘Requires Improvement’ although site visits took place back in 2016/17/18. When asked, the CQC told The Lowdown that there is monitoring of the hospitals that received low ratings and an action plan is drawn up for improvement. In cases where a provider has breached the legally enforceable regulations the CQC does have a range of enforcement powers to ensure improvement and keep people safe.
The HSIB report has given the CQC more to do on the safety of the independent sector with two recommendations: developing ways to monitor the lines of communication between the NHS and the independent sector to avoid confusion of responsibility and that the regulation of integrated care systems includes ways to check and monitor the surgical pathways between independent providers and the NHS.
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